Toronto Notes Gems Flashcards Preview

► Med Misc 43 > Toronto Notes Gems > Flashcards

Flashcards in Toronto Notes Gems Deck (66):
1

6 As of General Anesthesia

Anesthesia
Anxiolysis
Amnesia
Areflexia (muscle relaxation not always required)
Autonomic Stability
Analgesia

2

Discuss β-blockers (b1 vs. b2) & its cautions

• b1 receptors are located primarily in the heart and kidneys
• b2 receptors are located in the lungs
• Non-selective b-blockers block b1 and b2 receptors. Caution is required with non-selective b-blockers, particularly in patients with respiratory conditions
where b2 blockade can result in
airway reactivity

3

Pre-Anesthetic Checklist

SAMMM

- Suction: connected and working
- Airways: laryngoscope and blades, ETT, syringe, stylet, oral and nasal airways, tape, bag and mask
- Machine: connected, pressures okay, all meters functioning, vaporizers full
- Monitors: available, connected and working
- Medications: IV fluids and kit ready, emergency medicines in correct location and accessible

4

Suspect Difficult Bag-Mask Ventilation with:

BONES

Beard
Obesity/Obstetrics
No teeth
Elderly
Sleep apnea

5

Differential Diagnosis of Poor Bilateral Breath Sounds after Intubation

DOPE

Displaced ETT
Obstruction
Pneumothorax
Esophageal intubation

6

Causes of Intraoperative Shock

SHOCKED

Sepsis or Spinal shock
Hypovolemic/Hemorrhagic
Obstructive
Cardiogenic
anaphylactiK
Extra/other
Drugs

7

Discuss Opioid Equivalency for morphine, codeine, oxycodone & hydromorphone

• 10 mg morphine
• 100 mg codeine
• 5 mg oxycodone
• 2 mg hydromorphone

8

Use NSAIDs with Caution in Patients with:

• Asthma
• Coagulopathy
• GI ulcers
• Renal insufficiency
• Pregnancy, 3rd trimester

9

Common Side Effects of Opioids

• Nausea and vomiting
• Constipation
• Sedation
• Pruritus
• Abdominal pain
• Urinary retention
• Respiratory depression

When prescribing opioids, consider:
• Breakthrough dose
• Anti-emetics
• Laxative

10

Classic Presentation of Dural Puncture Headache

• Onset 6 h-3 d after dural puncture
• Postural component (worse sitting)
• Occipital or frontal localization
• ± tinnitus, diplopia

11

Differential of ST Segment Changes

ST Elevation “I HELP A PAL”

- Ischemia with reciprocal changes
- Hypothermia (Osborne waves)
- Early repolarization (normal variant; need old ECGs)
- LBBB
- Post-MI
- Acute STEMI
- Prinzmetal’s (Vasospastic) angina
- Acute pericarditis (diffuse changes)
- Left/right ventricular aneurysm

ST Depression “WAR SHIP”

- WPW syndrome
- Acute NSTEMI
- RBBB/LBBB
- STEMI with reciprocal changes
- Hypertrophy (LVH or RVH) with strain
- Ischemia
- Post-MI

12

Important Contraindications to
Exercise Testing

• Acute MI, aortic dissection,
pericarditis, myocarditis, PE
• Severe AS, arterial HTN
• Inability to exercise adequately

13

Treatment of NSTEMI/Immediate Treatment of Acute MI

BEMOAN

β-blocker
Enoxaparin
Morphine
O2
ASA
Nitrates

14

Complications of MI

CRASH PAD

Cardiac Rupture
Arrhythmia
Shock
Hypertension/Heart failure
Pericarditis/Pulmonary emboli
Aneurysm
DVT

15

Use Ejection Fraction to Grade LV
Dysfunction

• Grade I (EF >60%) (Normal)
• Grade II (EF = 40-59%)
• Grade III (EF = 21-39%)
• Grade IV (EF ≤20%)

16

Five Most Common Causes of CHF

• CAD (60-70%)
• HTN
• Idiopathic (often dilated
cardiomyopathy)
• Valvular (e.g. AS, AR and MR)
• Alcohol (dilated cardiomyopathy)

17

Precipitants (c.f. exacerbations) of Heart Failure

HEART FAILED

- Hypertension (common)
- Endocarditis/environment (e.g. heat wave)
- Anemia
- Rheumatic heart disease and other valvular disease
- Thyrotoxicosis
- Failure to take meds (very common)
- Arrhythmia (common)
- Infection/Ischemia/Infarction (common)
- Lung problems (PE, pneumonia, COPD)
- Endocrine (pheochromocytoma,
hyperaldosteronism)
- Dietary indiscretions (common)

18

Features of Heart Failure on CXR

HERB-B

Heart enlargement (cardiothoracic ratio >0.50)
Pleural Effusion
Re-distribution (alveolar edema)
Kerley B lines
Bronchiolar-alveolar cuffing

19

Discuss the regime with beta blocker use in acute on chronic HF patients

Patients on β-blocker therapy who have acute decompensated heart
failure should continue β-blockers
where possible (provided they are
not in cardiogenic shock or in severe pulmonary edema)

20

Chronic Treatment of CHF

• ACE inhibitors*
• β-blockers*
• ± Aldosterone antagonists* (if severe CHF) e.g. spironolactone
• Diuretic
• ± Inotrope
• ± Antiarrythmic
• ± Anticoagulant

*Mortality benefit

21

(4) types of Cardiomyopathy

HARD

- Hypertrophic cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy
- Restrictive cardiomyopathy
- Dilated cardiomyopathy

22

(3) Major Risks Factors for DCM

Alcohol, cocaine, family history

23

Acute Pericarditis Triad

• Chest Pain
• Friction Rub
• ECG Changes

24

Ewart’s Sign

Bronchial breathing and dullness to percussion at the lower angle of the left scapula in pericardial effusion due to effusion compressing left lower lobe of lung.

25

Classic Quartet of Tamponade

• Hypotension
• Increased JVP
• Tachycardia
• Pulsus paradoxus

26

Beck’s Triad in cardiac tamponade

• Hypotension
• Increased JVP
• Muffled heart sounds

27

DDx Pulsus Paradoxus

• Constrictive pericarditis (rarely)
• Severe obstructive pulmonary disease (e.g. asthma)
• Tension pneumothorax
• PE
• Cardiogenic shock
• Cardiac tamponade

28

Symptoms of Acute Limb Ischemia

6 Ps – all may not be present

- Pain: absent in 20% of cases
- Pallor: within a few hours becomes mottled cyanosis
- Paresthesia: light touch lost first then sensory modalities
- Paralysis/Power loss: most important, heralds impending gangrene
- Polar/Poikilothermia (cold)
- Pulselessness: not reliable

29

Classic Triad of Ruptured AAA

• Pain
• Hypotension
• Pulsatile abdominal mass

30

Trousseau’s disease/sign

Migratory superficial thrombophlebitis is often a sign of underlying malignancy

31

Antiarrythmic Drug Classification

Some Block Potassium Channels

I – Sodium channel blocker
II – β-Blocker
III – Potassium channel blocker
IV – CCB

32

The Cockcroft-Gault Equation (estimate creatinine clearance (CrCl) in adults 20 yr of age and older)

• For males CrCl (mL/min) =
[(140 – age in yr) x Weight (kg)] x 1.2 / serum Cr (μmol/L)

• For females, multiply above equation x 0.85
• Only applies when renal function is at steady state

33

How many half lives does it need to reach steady state with repeated dosing or to eliminate a drug once dosing is stopped?

For most drugs it takes 5 half-lives

34

Keloids vs. Hypertrophic Scars

• Keloids: extend beyond margins
of original injury with claw-like
extensions
• Hypertrophic scars: confined to
original margins of injury

35

DDx of Hyperpigmented Macules

• Purpura (e.g. solar, ASA, anticoagulants,
steroids, hemosiderin
stain)
• Post-inflammatory
• Melasma
• Melanoma
• Fixed drug eruption

36

ABCDE of Melanoma

Asymmetry
Borders (irregular)
Colour (variegated)
Diameter (>6 mm)
Evolution (over time)

37

Triggers for Atopic Dermatitis

• Irritants (detergents, solvents,
clothing, water hardness)
• Contact allergens
• Environmental aeroallergens (dust mites)
• Inappropriate bathing habits (long hot showers)
• Sweating
• Microbes (S. aureus)
• Stress

38

PSORIASIS: Presentation and
Pathophysiology

- Pink papules/Plaques/Pinpoint bleeding (Auspitz sign)/Physical injury (Koebner phenomenon)
- Silver scale/Sharp margins
- Onycholysis/Oil spots
- Rete Ridges with Regular elongation
- Itching
- Arthritis/Abscess (Munro)/Autoimmune
- Stratum corneum with nuclei
- Immunologic
- Stratum granulosum absent

39

PSORIASIS: Triggers

• Physical trauma (Koebner phenomenon)
• Infections (acute streptococcal
infection precipitates guttate psoriasis)
• Stress (can be a major factor in flares)
• Drugs (systemic glucocorticoids, oral lithium, antimalarial drugs, interferon)
• Alcohol ingestion

40

Drug Hypersensitivity Syndrome Triad

• Fever
• Exanthematous Eruption
• Internal Organ Involvement

41

Risk Factors for Melanoma

no SPF is a SIN

- Sun exposure
- Pigment traits (blue eyes, fair/red hair, pale complexion)
- Freckling
- Skin reaction to sunlight (increased incidence of sunburn)
- Immunosuppressive states (e.g. renal transplantation)
- Nevi (dysplastic nevi; increased number of benign melanocytic nevi)

42

Initial Management of Any Patient in Shock

• ABCs
• IV fluids
• Oxygen
• Monitor (HR, BP, urine, mentation, O2 saturation)
• Control hemorrhage

43

NG Tube Contraindications

• Significant mid-face trauma
• Basal skull fracture

44

Unilateral, Dilated, Non-reactive
Pupil, think:

• Focal mass lesion
• Epidural hematoma
• Subdural hematoma

45

Signs of Increased Intracranial
Pressure (ICP)

• Deteriorating LOC (hallmark)
• Deteriorating respiratory pattern
• Cushing reflex (high BP, low heart rate, irregular respirations)
• Lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis)
• Seizures
• Papilledema (occurs late)
• Nausea/vomiting and headache

46

Signs of Basal Skull Fracture

• Battle’s sign (bruised mastoid process)
• Hemotympanum
• Raccoon eyes (periorbital bruising)
• CSF Rhinorrhea/Otorrhea

47

Treatment of Increased ICP

• Elevate head of bed
• Mannitol
• Hyperventilate
• Paralyzing/sedating agents

48

Seatbelt Injuries may Cause:

• Retroperitoneal duodenal trauma
• Intraperitoneal bowel transection
• Mesenteric injury
• L-spine injury

49

Reasons for Emergent Orthopedic Consultation

• Compartment syndrome
• Irreducible dislocation
• Circulatory compromise
• Open fracture
• Injury requiring surgical repair

50

Vascular injury/compartment syndrome is suggested by “The 6 Ps”:

- Pulse discrepancies
- Pallor
- Paresthesia/hypoesthesia
- Paralysis
- Pain (especially when refractory to usual analgesics)
- Polar (cold)

51

Acute Treatment of Contusions

RICE

Rest
Ice
Compression
Elevation

52

Where NOT to use local anesthetic with epinephrine:

Ears, Nose, Fingers, Toes and Penis

53

Gynecological Causes of Pelvic Pain:

• Ovarian cyst
• Dysmenorrhea
• Mittelshmerz
• Endometriosis
• Ovarian torsion
• Uterine fibroids/neoplasm
• Adnexal neoplasm
• PID + cervicitis

54

Signs of PE on CXR

Westermark’s sign: abrupt tapering of a vessel on chest film.

Hampton’s hump: a wedge-shaped infiltrate that abuts the pleura.

55

Causes of Syncope by System

HEAD, HEART, VeSSELS

Hypoxia/Hypoglycemia
Epilepsy
Anxiety
Dysfunctional brainstem

Heart attack
Embolism (PE)
Aortic obstruction
Rhythm disturbance
Tachycardia

Vasovagal
Situational
Subclavian steal!!
ENT (glossopharyngeal neuralgia)
Low systemic vascular resistance
Sensitive carotid sinus

56

Treatment of Asthma

ASTHMA

Adrenergics (β-agonists)
STeroids
Hydration
Mask (O2)
Antibiotics (if concurrent bacterial
pneumonia)

57

If patient has Wolff-Parkinson-White and is in AFib use [...]. Avoid [...] agents as this can increase conduction through bypass tract leading to cardiac arrest

use amiodarone or procainamide.

Avoid AV nodal blocking agents (adenosine, digoxin, diltiazem, verapamil, betablockers)

58

Causes of CHF Exacerbation (c.f. precipitants)

FAILURE

Forgot medication
Arrhythmia (Dysrhythmia)/Anemia
Ischemia/Infarction/Infection
Lifestyle (e.g. too much salt)
Upregulation of cardiac output
(pregnancy, hyperthyroidism)
Renal failure
Embolism (pulmonary)

59

Acute Treatment of CHF

LMNOP

Lasix (furosemide)
Morphine
Nitroglycerine
Oxygen
Position (sit upright), Pressure (BiPAP)

60

Risk Factors for VTE

THROMBOSIS

Trauma, travel
Hypercoagulable, HRT
Recreational drugs (IVDU)
Old (age >60)
Malignancy
Birth control pill
Obesity, obstetrics
Surgery, smoking
Immobilization
Sickness (CHF, MI, nephrotic syndrome, vasculitis)

61

Precipitating Factors in DKA

The 5 Is

Infection
Ischemia
Infarction
Intoxication
Insulin missed

62

4 Criteria for DKA Dx

• Hyperglycemia
• Metabolic acidosis
• Hyperketonemia
• Ketonuria

63

HELLP Syndrome (seen only in
preeclampsia/eclampsia)

Hemolytic anemia
Elevated Liver enzymes
Low Platelet count

64

Causes of Acute Ataxia

UNABLE TO STAND

- Underlying weakness (mimic ataxia)
- Nutritional neuropathy (vitamin B12 deficiency)
- Arteritis/vasculitis
- Basilar migraine
- Labyrinthitis/vestibular neuronitis
- Encephalitis/infection
- Trauma (post-concussive)
- Other (rare genetic or metabolic disease)
- Stroke (ischemia or hemorrhage)
- Toxins (drugs, toluene, mercury)
- Alcohol
- Neoplasm/paraneoplastic syndrome
- Demyelination (Miller Fisher, Guillain Barré, MS)

65

(3) main types of Kidney Stones

• 80% Calcium
• 10% Struvite
• 10% Uric acid

66

High Risk Criteria for Infection of wounds

Wound Factors
• Puncture wounds
• Crush injuries
• Wounds >12 h old
• Hand or foot wounds
• Wounds near joints

Patient Factors
• Immunocompromised
• Age >50 yr
• Prosthetic joints or valves

Decks in ► Med Misc 43 Class (80):